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Leg: Achilles Tendonitis

The early-season ice flows of Silverton, Colorado, sit at almost 12,000 feet. Having just flown in from coastal Maine, I huffed the thin air on the approach to Stairway to Heaven (WI 4). As we traversed the hillside, I noticed that not only were my lungs searing, but my ankle throbbed due to a bad case of Achilles tendonitis, acquired while training for a mountaineering trip the year before. The steep approach wasn’t helping matters and my ankle had just been stuffed in climbing boots for the first time that season.

As I led up the fourth pitch I heaved to catch a full breath, hesitating one move away from pulling the bulge below the next belay. The ice in front of me was thin, candled and poorly bonded. I grew weak as I hung from my right arm, trying desperately to get a solid stick with my off-hand.

I tried to remind myself to drop my heels, but the more anxious I became the more I leaned into the ice and up on my frontpoints. With one last effort I swung my left tool. It skipped off the rock and threw me off balance. My right toe popped out and all of my weight crashed down on my left frontpoint. I felt an intense burning in my left ankle. My Achilles tendon had ruptured.

I fell onto a tied-off stubby ice screw and landed on my partner’s pack, tearing it from the anchor and sending it down into the river. The next five hours consisted of shaky raps from V-threads, followed by an exhausting one-legged posthole traverse back to the van.

Tendonitis For Everyone!

About 30 percent of all climbers will deal with some degree of Achilles tendonitis over their lifetimes. Most physicians who treat climbers attest that Achilles tendonitis is probably the most common climbing-related condition overall. Still, it’s hard to know exactly how prevalent it is. Accumulating data on the exact incidence of Achilles tendonitis is difficult. Many climbers who have it do not seek medical attention, and few climbing-specific studies have been done on Achilles tendonitis.

What has been studied is the link between hiking, running and tendonitis. One study published in Clinics in Sports Medicine (January 2004) found that the annual incidence of Achilles tendonitis in runners is around seven to nine percent. Considering many climbers cross-train or run, and that 50 percent of cases result from overuse, Achilles tendonitis is one of the most common training injuries. The American Journal of Medicine (March 2003) published a study showing that 20 percent of subjects who were backpacking or mountaineering for more than seven consecutive days sustained Achilles tendonitis. According to that data, anyone planning a technical enchainment, alpine climb with a long approach or ascent of a glaciated peak may encounter Achilles pain.

Achilles tendonitis is more common in mountaineers than craggers since the demands of rock climbing put more stress on the elbows than the ankles, but if you’re a sport climber or boulderer, you are still at risk.

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The biggest complication of tendonitis, aside from chronic pain, is tendon rupture. While tendonitis alone can end your climbing season, a blown Achilles can end your climbing career. Rupture can occur if the tendon becomes compromised. When Achilles tendonitis becomes chronic, the prolonged inflammation leads to thickening of the tendon with microscopic tears, calcium deposits and disorganized scar tissue. These structural changes, referred to as tendonosis, weaken the tendon. The simple act of “toeing off” during a sprint puts the stress equivalent of a static load over 10 times your body weight on a single Achilles tendon. Now picture the stress of a dyno or the cumulative stress of 5,000 vertical feet of glacier plodding with a 50-pound pack on a significantly weakened tendon and it’s easy to see how that tendon might snap.

Achilles What?

Unlike ligaments, which link bones together, tendons tie the end of muscles to bone. The Achilles tendon connects the two major calf muscles, the gastrocnemius and soleus, to the calcaneus (heel bone).

As you walk, the calf muscles contract, yanking on the Achilles tendon. This flips your toes under your foot as you “toe off” against the ground and your calcaneus rocks upward. When you finish your stride and are preparing to land your heel, you lift your toes up, which rolls the calcaneus bone back to its original position.This back-and-forth rocking action consistently rolls the Achilles tendon against the back of the calcaneus bone, causing abrasion.

This abrasion would wear out a tendon in a few weeks, but our bodies are designed for longevity. Tendons are equipped with a protective sheath, usually filled with fluid that lubricates the tendon as it slides over rough surfaces. In addition, a small pocket of fluid, called a bursa, acts as a pad at the point where a tendon repeatedly rolls over an edge of bone. The bursa, the protective sheath (usually called a synovial sheath or, in the case of the Achilles, a paratendon) or the tendon itself can all become inflamed. When the tendon, not the surrounding tissue, becomes inflamed, you’ve got Achilles tendonitis.

Why Me?

Achilles tendonitis has two major causes: overpronation and overuse. Pronation is the act of pressing your toes against the ground, forcing them in a down-and-out direction. This act partially collapses the arch of your foot. Normally, this wouldn’t be a problem, but if you have poor arch support in your shoes, are flatfooted or wear shoes that fail to stabilize the heel, your heel will roll slightly and your arch can collapse too much. This causes rotation of the calcaneus, friction near the lower Achilles, and eventually tendonitis.

Overuse is a relative term. Some climbers will transition from weekly to daily sport climbing without a problem. Others might suffer an inflamed Achilles out of the blue. A common misconception is that only weekend warriors acquire Achilles tendonitis. Certainly their activity pattern is more likely to cause the condition because the tendon is at rest for long periods of time, where it contracts and becomes tight. If, after this lack of use, you embark on a three-day climb of Mount Rainier, for example, the Achilles will almost certainly scream. However, any significant change in exercise pattern, if not executed carefully, can lead to tendonitis. It’s common for guides or daily climbers to feel the flame in their heels when they start training for an expedition, work a hard problem or return to climbing after a hiatus.

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If you have Achilles tendonitis you may not know it. Pain in the heel can be due to a number of other problems, such as bursitis or stress fractures. Typically, Achilles tendonitis occurs gradually, over months. It can occur more suddenly, however, especially if put under an extraordinary amount of stress without prior training or stretching.

Pain—burning or aching—is the most common symptom of Achilles tendonitis. The Achilles may feel slightly thick, and you may notice a grinding sensation when you pull back on your toes. Stretching may cause pain. In addition, you may notice shocks of pain when descending stairs or trails. There’s usually no dramatic swelling or redness.

Prevention is Another Word for Love

Make sure you have proper footwear and arch support. Dropping molded insoles into your approach shoes or climbing boots will help. Make sure you stretch for a good 15 minutes before climbing. Remember that if you’re using your feet, you’re stressing your Achilles. Perform calf-strengthening exercises (see below), which decrease the frequency of tendon flares.

If you’re training for a long climb or expedition, start slowly. According to the American College of Sports Medicine, athletic training errors cause 60 to 80 percent of Achilles injuries. Overambitious distances or pack weights early in a training regimen may send you on the trip of your dreams with a bum leg.If you can’t get out on the trails to train,use a Stairclimber or elliptical trainer machine. However you train, increase the intensity of your workout gradually, allowing your Achilles to adapt to the daily insult of a heavy pack and long miles. Most important, listen to your body. If it hurts, rest it and treat it.

Be Patient, Be Healed

It’s not easy to get rid of Achilles tendonitis. The mainstays of treatment include a diligent regimen of at-home tendon-strengthening stretches, rest from repetitive injury (don’t go running, for instance) and anti-inflammatory medications (mentioned below). Institute all of these methods concurrently at the first sign of Achilles tendonitis.

For your stretching, face a wall, plant your foot firmly on the floor about two or three feet from the wall and gradually lean into the wall, stretching your heel while keeping it pinned to the floor. Do this for 30 seconds, relax for a minute and repeat. Do five to 10 reps and repeat these sets a few times per day. Whatever you do, don’t skip the first session of the day, which you should do as soon as you get out of bed. Your foot has been in a dropped position all night and the Achilles is contracted and tight. This is the most important time to rehabilitate it.

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Newer evidence has shown that eccentric (tendon-lengthening) stretches are also effective for treating Achilles tendonitis. Stand on a low step with only your toes on the step and your heel hanging off the edge. Push up high on the toes of the problem foot, bearing weight only on that foot, balancing against the wall if needed. Over a 10-second period, lower your heel from its high position until it again drops off the edge of the step. Repeat this routine 10 times, three times a day, for 12 weeks.

Try not to stress your Achilles for a one to three weeks, depending on the severity of the tendonitis. If you suffer from chronic tendonitis, longer periods of rest may be needed. Be sure to wear shoes with proper arch and heel support. Ice your heel. There’s conflicting evidence regarding the benefit of ice, but most experts agree it decreases inflammation. Icing your Achilles for 30 minutes after exercise may help shorten the duration of a tendonitis flare. Another option is to apply ice for 15 minutes on, remove it for 15 minutes and repeat for four to six cycles. If nothing else it’ll keep you on the couch so you can rest your tendon.

While you are stretching and icing, try a course of anti-inflammatories. Early initiation of oral anti-inflammatories is perhaps the most effective treatment (even more than stretching) for warding off Achilles tendonitis. You may be able to get away with as-needed anti-inflammatories, like ibuprofen, but a 10-day burst of around-the-clock anti-inflammatory use is more effective, especially if this is your first bout with Achilles tendonitis. While over-the-counter doses may help, most doctors advise a higher dose for better inflammatory control. Talk to your doctor before starting anti-inflammatories, as these drugs can cause stomach ulcers or bleeding and have long-term health consequences.

If those conservative treatments fail, see your doctor and pull out the big guns. Ankle splints, ultrasound treatment, casting and even surgery are all more aggressive options that can help treat Achilles tendonitis. However, with proactive conservative treatment these drastic measures will likely never be needed.

Last year I was slithering up a narrow chimney near the top of Bugaboo Spire. I jammed my left foot in a perfect crack deep inside the slot, weighted it, and fiddled with gear, trying to yank a cam from my tangled rack. Suddenly a twinge of pain shot from my ankle up into my calf. It took my breath away.

As I quaked and tried to avoid peeling off, I thought back to my incident on Stairway to Heaven. I pushed down with my left foot. It worked perfectly. I had been rehabilitating my Achilles all spring, just as I have every year since my accident in Silverton. I was lucky that day in Colorado. My Achilles only partially ruptured. It’s much better now, but occasionally it hurts. Every now and then, on a slab or in a steep couloir, it’ll talk to me and remind me to do my exercises.

Dr. Brian Irwin is a family practitioner from North Conway, New Hampshire. He still hasn’t finished Stairway to Heaven.